Application for Employment Today s Date: PERSONAL DATA Name: Last: First: Middle: Current Address: City: State: Zip: Phone: Day ( ) Evening ( ) How or by whom were you referred? Social Security No. Date of Birth If hired and under 18, can you furnish a work permit? Yes No I am over 18 Are you legally authorized to work in the United States? Yes No (If hired, you will be required to submit proof of your identity and legal work authorization as a condition of employment.) Do you have specific salary requirements? Yes No If yes, please indicate: EMPLOYMENT DATA Date available for work: Total hours available per week: Type of hours: Full time Part time Days* Nights* *Hours: Regular Temporary/What date will you no longer be available to work? Will you work overtime if necessary? Yes No If yes, how many hours per week? Are there any days or hours you are unable or unwilling to work? If yes, write specifics below: Do you have transportation to/from work? Yes No Do you have a valid Driver s License? Yes No
AN EQUAL OPPORTUNITY/DRUG-FREE EMPLOYER We are an equal opportunity employer and do not discriminate against any applicant because of race, color, religion, sex, national origin, age, disability, sexual orientation, marital status, or any other class protected by federal, state, or local law. EDUCATION High School: Name City Circle highest grade completed: High School: 9 10 11 12 College: 13 14 15 16 17 Diploma or GED: Yes No If applicable, please check all your skills: WORKING SKILLS Maintenance Customer Service Janitorial Equipment Operation Janitorial equipment used: Describe any other ability, experience or aptitude which you believe would be helpful in your job: The position may require lifting (50 lbs.), do you have any weight restrictions? Yes No If yes, please list restrictions: MEDICAL I understand and agree that I may be required to undergo and successfully pass a screening for alcohol and/or drugs during the hiring process and if employed, as required by the company. Signature:
EMPLOYMENT RECORD INFORMATION
Read this carefully before answering the following questions: SECURITY You may answer No if your criminal record consists only of one or more of the following: (a) a sealed record on file with the Commissioner of Probation, (b) a case of delinquency or a child in need of services which did not result in a complaint transferred to Superior Court for criminal prosecution, (c) your crimes were misdemeanors and they occurred five or more years ago, or (d) your misdemeanors were limited to a first offense for drunkenness, simple assault, speeding, minor traffic offenses, disturbance of the peace, or affray. Have you been convicted of a felony or misdemeanor? Yes No If yes, give details including date, location (city) nature of offense and disposition. Note: a conviction record will not necessarily be a bar to employment. READ CAREFULLY BEFORE SIGNING: SIGNATURE 1. I understand that the receipt of this application does not imply that I will be employed. 2. The statements and information furnished by me in this application are true and complete. I understand that I will be subject to immediate dismissal or refusal to hire if at anytime Universal Cleaning discovers any material falsification, omission, or misrepresentation of fact in this application. 3. I authorize Universal Cleaning to conduct a background inquiry to verify the statements and information on this application, other documentation that I have provided, and other areas that may include prior employment, criminal convictions, motor vehicle history, and other reports. I authorize all previous employers or other persons who have knowledge of me, or my records, to release such information to Universal Cleaning. I hereby release any individual, agency, and Universal Cleaning from all claims or liabilities whatever that may arise from the disclosure of such information. 4. I understand that all employees of Universal Cleaning are employees at will. If hired, I will be free to resign at any time. Likewise, Universal Cleaning will have the right to terminate my employment at any time with or without any reason or notice, regardless of the date of payment of my wages or salary. Neither this application, or any other documents given to employees is intended to create, nor should such documents be constructed as creating, an express or implied contract. My Signature Certifies That I Have Read And Agree With The Above Statements. Signature of Applicant Date
REFERENCES Name: Date: Professional References Please list 3 professional references who can verify your work history and performance. References should not be relatives and at least two must have directly supervised you at some time in your work history. 1. Name of Supervisor Title Company Name and Address 2. Name of Supervisor Title Company Name and Address 3. Name of Supervisor Title Company Name and Address Personal References Please list 2 personal references (must not be a relative). 1. Name and Address Phone number ( ) Years Acquainted How do you know this individual? 2. Name and Address Phone number ( ) Years Acquainted How do you know this individual?